Analysis of clinical manifestations of lumbar spinal stenosis

Lumbar spinal stenosis (LSS), being well determined from a morphological point of view, is heterogeneous in clinical manifestations. Polymorphism of clinical syndromes in patients with lumbar spinal stenosis suggests diffuseness of morphological changes in the structures of the spinal canal and their ambiguity.

The walls of the spinal canal are lined by the outer plate of the dura mater of the spinal cord and are formed by bony (posterior part of the vertebral body, roots of the arches, facet joints) and ligamentous (posterior longitudinal ligament, yellow ligaments) formations, as well as the intervertebral disc. Each structure may play a role in the clinical syndromes of lumbar spinal stenosis.

The clinical core of lumbar spinal stenosis is represented by various pain, neurodystrophic and vegetative-vascular disorders, which, as a rule, are subcompensated and have little effect on the patient's quality of life. According to L. A. Kadyrova, from a clinical and anatomical point of view, lumbar spinal stenosis continues to be the Cinderella of modern neuro-orthopedics.

According to the magnetic resonance imaging data analyzed by us, the basis of the mechanisms of lumbar spinal stenosis formation are hyperplastic and dislocation processes in the spine: decrease in the height of the disc, antelisthesis, retrolisthesis and lateralisthesis of the vertebrae, dislocation of the facet joints, osteophytes of the vertebral bodies, hyperplastic deformation of the arches and articular processes, osteophytes of the articular facets, hypertrophy and ossification of the posterior longitudinal and yellow ligaments, leading to a decrease in the size of the central part of the spinal canal, its lateral pockets.

It is obvious that in order to reveal the mechanism of formation of clinical manifestations of lumbar spinal stenosis, it is necessary to compare the maximum number of clinical syndromes with the data of radiation and magnetic resonance studies of the lumbar spine.

The aim of our work was to analyze the features of clinical manifestations of lumbar spinal stenosis in patients.

A total of 317 patients aged 48 to 79 years were examined. They were treated at the State Institution "M. I. Sitenko Institute of Post-Correctional Surgery of the National Academy of Medical Sciences of Ukraine" from 2008 to 2011 and were diagnosed with lumbar spinal stenosis as a result of clinical, radiological and MRI examination. The patients were divided into two groups: Group I (n = 137) included patients with lumbar spinal stenosis and persistent neurological deficit, Group II (n = 180) included patients with lumbar spinal stenosis and signs of objective transient neurological disorders.

All subjects underwent a comprehensive clinical and neurological examination, a study using the scale for quantitative assessment of the severity of neurological disorders (Z), the scale of the overall severity of disability before and after treatment (Oswestri), the JOA scale (the scale of the Japanese Orthopedic Association), the ASIA scale, and the Barthel ADL Index was determined.

Statistical processing of the results was performed using the Statistica v. 6.1 program (StatSoft Inc., USA). The degree of interrelation of individual indicators was calculated using paired and multiple correlation analysis methods. The reliability of differences was determined using Student's t-test.

Most often, the first symptom was algic, of varying severity, in the lumbar region (in 94.95% of patients) with irradiation to the lower limb(s) (in 78.86% of patients). The duration of the lumbago period varied - from several days to several years, then radicular pain in one or both legs joined. A detailed collection of anamnesis allowed us to distinguish two groups of patients: with a progressive-remitting course and with a relapsing course of the disease. In the first case, a steady increase in pain syndrome was observed and each subsequent exacerbation was accompanied by a decrease in the distance walked, i.e. signs of claudication were formed. In the group with a relapsing course, an increase and decrease in pain syndrome alternated, however, according to patients, this did not affect the duration of walking. An interesting fact, in our opinion, was that the majority of patients with progressive-remitting course of pain syndrome were represented by patients of group I.

The results of our observations showed that one of the early signs of lumbar spinal stenosis are painful cramps - a peculiar and poorly studied sign of lumbar spinal stenosis, related to paroxysmal disorders of the peripheral nervous system. In our study, they were noted in 39.41% and 21.11% of patients in groups I and II, respectively, but were more common in patients with lateral stenosis and damage to several roots on one side. Cramps occurred together with the first painful sensations in individual muscle groups, more often in the gastrocnemius muscles, less often in the gluteal muscles and adductor muscles of the thigh.

The JOA score was higher in patients of group II, which, in our opinion, is absolutely justified due to the absence of signs of neurological deficit in this category of patients. The ADL scale showed a decrease in the level of daily activity by groups without statistically significant differences. The average values of the overall severity of neurological disorders were the lowest in the group of patients with central stenosis, the average values of the Z scale in patients of group I showed the presence of more severe neurological changes in patients with lateral stenosis. When studying the dependence of the indicators included in the Oswestry Index Questionare on the observation group, it was found that the presence of neurological disorders, as expected, worsened the well-being and, accordingly, the quality of life of patients with lumbar spinal stenosis.

The average number of points of the sensory and motor parts of the ASIA scale topically corresponded to the level of radiculocaudal deficit present in patients and indicated more severe damage to the roots of the cauda equina in the subgroups with lateral and combined lumbar stenosis.

According to the literature, the classic and most common manifestation of lumbar spinal stenosis is neurogenic intermittent claudication (NIC). This was confirmed by our study. Anamnestically, almost all patients showed clinical precursors of neurogenic intermittent claudication in the form of increased pain or transient symptoms of prolapse, occurrence of pain, numbness and weakness in the legs when walking; the symptoms regressed when the patient stopped and leaned forward.

Neurogenic intermittent claudication was noted in 81.02% of patients in group I and in 76.66% of patients in group II and in our study it was divided by clinical and topographic features into caudogenic and radiculogenic claudication. The most common form of claudication was caudogenic intermittent claudication - in 64.86% of patients in group I and in 70.29% of patients in group II; unilateral radiculogenic claudication was noted in 35.14% and 29.71% of patients, respectively. Caudogenic claudication was most often found in the group of patients with combined spinal stenosis - in 36.93% and 40.58% of patients in subgroups 1C and 2C, respectively.

Severe claudication (< 100 m) was noted in 24.32% of patients in Group I and in 30.43% of patients in Group II. A distance of 100 to 200 m during a marching test was assessed as severe claudication (28.82% and 28.98% of patients, respectively). Moderate claudication (200-500 m) was detected in the majority (46.85% and 40.58% of patients in the observed groups). No statistically significant differences were found across subgroups.

Among people under 54 years of age, the greatest number of cases of severe claudication was noted - 15.67% of patients. In the age group from 55 to 71 years, all degrees of claudication were encountered with approximately the same frequency. In the group of patients over 72 years of age, claudication was more often moderately expressed (16.06%).

We observed a direct correlation between NPH and excess weight and chronic venous insufficiency of blood circulation in the lower extremities (p < 0.0005, r = 0.77). A weaker but statistically significant correlation between NPH and hypertension was also found (p < 0.0021, r = 0.64). However, no statistically significant difference was found between the subgroups.

Our data show that radicular syndrome was observed more often than others in the observed patients - in 125 (91.24%) patients of group I. Monoradicular syndrome was more often diagnosed in subgroup IB (30%), biradiculopathy was equally common in subgroups IA and 1C (24.14% and 24.49%), compression was more often polyradicular in patients of subgroup 1C (18.97%); polyradiculopathy was not observed in subgroup IB.

Sensitive changes were not specific depending on the observation group. Movement disorders were diagnosed in 86.13% of patients in group I. The most common were decreased muscle strength in the extensors (25.55%) and flexors of the feet (18.98%), weakness of the long extensor of the big toe and the quadriceps femoris in 14.59% of patients, and the triceps surae in 10.94%, which corresponded to the level of lumbar spinal stenosis. Among patients in group I with central stenosis, the severity of paresis was often limited to 3-4 points (84.44%). At the same time, among patients with mixed stenosis, paresis occurred with the same ratio of moderate and significant movement disorders (42.25% and 40.84%, respectively). In patients with lateral stenosis, paresis occurred in 72.41% of cases, while the ratio of moderate and severe paresis did not differ statistically (35.71% and 38.09%).

Vegetative disorders were observed in 30.61%, 63.33% and 55.17% of patients, respectively, in the form of a feeling of coldness and hyperhidrosis in the affected limb. Hypotrophy of the calf and gluteal muscles was moderate and always corresponded to the innervation zone of the affected root and, regardless of the group, was more often observed in patients with lateral stenosis (66.67% of patients).

Sphincter disorders were absent in patients with lateral stenosis and were more often observed in the group of patients with combined lumbar spinal stenosis - 37.93%.

We found a positive correlation (p < 0.05, r = 0.884) between hypertrophy of the facet joints and increased pain during load tests. In addition, in patients with spondyloarthrosis, we noted significantly (p < 0.05) lower (5.9+1.13) JOA scale scores, i.e. these patients had a worse functional state of the lumbar spine compared to patients without spondyloarthrosis changes (6.8±1.23).

Thus, our study confirmed the polymorphism of clinical syndromes in patients with lumbar spinal stenosis. The results of complex diagnostics for lumbar spinal stenosis allow us to state that only a comprehensive examination of patients using not only visualization methods of research, but also a detailed clinical analysis will make it possible to develop rational treatment tactics and predict disease outcomes. To reveal the mechanism of formation of clinical manifestations of lumbar spinal stenosis, it is necessary to compare clinical and visualization data, as well as take into account the identified correlations.

PhD I. F. Fedotova. Analysis of clinical manifestations of lumbar spinal stenosis // International Medical Journal No. 4 2012

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